Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial

Chan-Mei Ho-Henriksson, Mikael Svensson, Carina A Thorstensson, Lena Nordeman, Chan-Mei Ho-Henriksson, Mikael Svensson, Carina A Thorstensson, Lena Nordeman

Abstract

Background: Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial.

Methods: Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve.

Results: 69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72-80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care.

Conclusion: These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients' perception of this model of care are needed.

Clinical trial registration: The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533.

Keywords: Cost-efficiency; Direct access; Health care process; Knee osteoarthritis; Physiotherapist; Primary care; Triage.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Health care pathways
Fig. 2
Fig. 2
Flow chart of available cases for QALY analyses
Fig. 3
Fig. 3
Cost-effectiveness plane societal perspective
Fig. 4
Fig. 4
Cost-effectiveness plane health care perspective
Fig. 5
Fig. 5
Cost-effectiveness acceptability curve: societal perspective
Fig. 6
Fig. 6
Cost-effectiveness acceptability curve: health care perspective

References

    1. Safiri S, Kolahi AA, Smith E, Hill C, Bettampadi D, Mansournia MA, Hoy D, Ashrafi-Asgarabad A, Sepidarkish M, Almasi-Hashiani A, et al. Global, regional and national burden of osteoarthritis 1990-2017: a systematic analysis of the global burden of disease study 2017. Ann Rheum Dis. 2020;79(6):819–828.
    1. Spencer LJ, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, Abbastabar H, Abd-Allah F, Abdela J, Abdelalim A, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. Lancet. 2018;392(10159):1789–1858.
    1. Wu M, Brazier JE, Kearns B, Relton C, Smith C, Cooper CL. Examining the impact of 11 long-standing health conditions on health-related quality of life using the EQ-5D in a general population sample. Eur J Health Econ. 2015;16(2):141–151.
    1. Gay C, Guiguet-Auclair C, Mourgues C, Gerbaud L, Coudeyre E. Physical activity level and association with behavioral factors in knee osteoarthritis. Ann Phys Rehabil Med. 2019;62(1):14–20.
    1. Palazzo C, Nguyen C, Lefevre-Colau MM, Rannou F, Poiraudeau S. Risk factors and burden of osteoarthritis. Ann Phys Rehabil Med. 2016;59(3):134–138.
    1. Finley CR, Chan DS, Garrison S, Korownyk C, Kolber MR, Campbell S, Eurich DT, Lindblad AJ, Vandermeer B, Allan GM. What are the most common conditions in primary care? Systematic review. Can Fam Physician. 2018;64(11):832–840.
    1. Turkiewicz A, Petersson IF, Bjork J, Hawker G, Dahlberg LE, Lohmander LS, Englund M. Current and future impact of osteoarthritis on health care: a population-based study with projections to year 2032. Osteoarthr Cartil. 2014;22(11):1826–1832.
    1. Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, Doherty M, Geenen R, Hammond A, Kjeken I, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72(7):1125–1135.
    1. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthr Cartil. 2019;27(11):1578–1589.
    1. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the Management of Osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2020;72(2):149–162.
    1. Bruyère O, Honvo G, Veronese N, Arden NK, Branco J, Curtis EM, Al-Daghri NM, Herrero-Beaumont G, Martel-Pelletier J, Pelletier JP, et al. An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of osteoporosis, osteoarthritis and musculoskeletal diseases (ESCEO) Semin Arthritis Rheum. 2019;49(3):337–350.
    1. Gwynne-Jones JH, Wilson RA, Wong JMY, Abbott JH, Gwynne-Jones DP. The outcomes of nonoperative management of patients with hip and knee osteoarthritis Triaged to a physiotherapy-led clinic at minimum 5-year follow-up and factors associated with progression to surgery. J Arthroplast. 2020;35(6):1497-503.
    1. Socialstyrelsen . Bedömning av tillgång och efterfrågan på legitimerad personal i hälso- och sjukvård samt tandvård - nationella planeringsstödet 2019. 2019.
    1. Culliford D, Maskell J, Judge A, Cooper C, Prieto-Alhambra D, Arden NK. Future projections of total hip and knee arthroplasty in the UK: results from the UK clinical practice research datalink. Osteoarthr Cartil. 2015;23(4):594–600.
    1. Long L, Moore D, Robinson S, Sansom A, Aylward A, Fletcher E, Welsman J, Dean SG, Campbell JL, Anderson R. Understanding why primary care doctors leave direct patient care: a systematic review of qualitative research. BMJ Open. 2020;10(5):e029846.
    1. Froment FP, Olson KA, Hooper TL, Shaffer SM, Sizer PS, Woodhouse LJ, Brismée JM. Large variability found in musculoskeletal physiotherapy scope of practice throughout WCPT and IFOMPT affiliated countries: an international survey. Musculoskelet Sci Pract. 2019;42:104–119.
    1. Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther. 2014;94(1):14–30.
    1. Piscitelli D, Furmanek MP, Meroni R, De Caro W, Pellicciari L. Direct access in physical therapy: a systematic review. Clin Ter. 2018;169(5):e249–e260.
    1. Babatunde OO, Bishop A, Cottrell E, Jordan JL, Corp N, Humphries K, Hadley-Barrows T, Huntley AL, van der Windt DA. A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain. Plos One. 2020;15(7):e0235364.
    1. Demont A, Bourmaud A, Kechichian A, Desmeules F. The impact of direct access physiotherapy compared to primary care physician led usual care for patients with musculoskeletal disorders: a systematic review of the literature. Disabil Rehabil. 2021;43(12):1637-48.
    1. Goodwin R, Moffatt F, Hendrick P, Timmons S, Chadborn N, Logan P. First point of contact physiotherapy; a qualitative study. Physiotherapy. 2020;108:29–36.
    1. Morris L, Moule P, Pearson J, Foster D, Walsh N. Patient acceptability of the physiotherapy first contact practitioner role in primary care: a realist informed qualitative study. Musculoskelet Care. 2021;19(1):38–51.
    1. Décary S, Fallaha M, Pelletier B, Frémont P, Martel-Pelletier J, Pelletier JP, Feldman DE, Sylvestre MP, Vendittoli PA, Desmeules F. Diagnostic validity and triage concordance of a physiotherapist compared to physicians’ diagnoses for common knee disorders. BMC Musculoskelet Disord. 2017;18(1):445.
    1. Sakellariou G, Conaghan PG, Zhang W, Bijlsma JWJ, Boyesen P, D'Agostino MA, Doherty M, Fodor D, Kloppenburg M, Miese F, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017;76(9):1484–1494.
    1. Moore JH, Goss DL, Baxter RE, DeBerardino TM, Mansfield LT, Fellows DW, Taylor DC. Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers. J Orthop Sports Phys Ther. 2005;35(2):67–71.
    1. Samsson KS, Grimmer K, Larsson MEH, Morris J, Bernhardsson S. Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies. BMC Musculoskelet Disord. 2020;21(1):673.
    1. Mallett R, Bakker E, Burton M. Is physiotherapy self-referral with telephone triage viable, cost-effective and beneficial to musculoskeletal outpatients in a primary care setting? Musculoskelet Care. 2014;12(4):251–260.
    1. Swinkels IC, Kooijman MK, Spreeuwenberg PM, Bossen D, Leemrijse CJ, van Dijk CE, Verheij R, de Bakker DH, Veenhof C. An overview of 5 years of patient self-referral for physical therapy in the Netherlands. Phys Ther. 2014;94(12):1785–1795.
    1. Denninger TR, Cook CE, Chapman CG, McHenry T, Thigpen CA. The influence of patient choice of first provider on costs and outcomes: analysis from a physical therapy patient registry. J Orthop Sports Phys Ther. 2018;48(2):63–71.
    1. Ludvigsson ML, Enthoven P. Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care. Physiotherapy. 2012;98(2):131–137.
    1. Malanga G, Niazi F, Kidd VD, Lau E, Kurtz SM, Ong KL, Concoff AL. Knee osteoarthritis treatment costs in the Medicare patient population. Am Health Drug Benefits. 2020;13(4):144–153.
    1. Losina E, Paltiel AD, Weinstein AM, Yelin E, Hunter DJ, Chen SP, Klara K, Suter LG, Solomon DH, Burbine SA, et al. Lifetime medical costs of knee osteoarthritis management in the United States: impact of extending indications for total knee arthroplasty. Arthritis Care Res. 2015;67(2):203–215.
    1. Hon S, Ritter R, Allen DD. Cost-effectiveness and outcomes of direct access to physical therapy for musculoskeletal disorders compared to physician-first access in the united states: systematic review and meta-analysis. Phys Ther. 2020;101(1):1-11.
    1. Ho C-M, Thorstensson CA, Nordeman L. Physiotherapist as primary assessor for patients with suspected knee osteoarthritis in primary care—a randomised controlled pragmatic study. BMC Musculoskelet Disord. 2019;20(1):329.
    1. Brazier JE, Harper R, Munro J, Walters SJ, Snaith ML. Generic and condition-specific outcome measures for people with osteoarthritis of the knee. Rheumatology. 1999;38:870–877.
    1. Walters SJ, Brazier JE. Comparison of the minimally important difference for two health state utility measures: EQ-5D and SF-6D. Qual Life Res. 2005;14(6):1523–1532.
    1. Nationella riktlinjer för rörelseorganens sjukdomar . Osteoporos, artros, inflammatorisk ryggsjukdom och ankyloserande spondylit, psoriasisartrit och reumatoid artrit. 2012.
    1. Thorstensson CA, Garellick G, Rystedt H, Dahlberg LE. Better management of patients with osteoarthritis: development and nationwide implementation of an evidence-based supported osteoarthritis self-management programme. Musculoskelet Care. 2015;13(2):67–75.
    1. Huskisson EC. Measurement of pain. Lancet. 1974;304(7889):1127–1131.
    1. Gill SD, de Morton NA, McBurney H. An investigation of the validity in six measures of physical function in people awaiting joint replacement surgery of the hip or knee. Clin Rehabil. 2012;26(19):945–951.
    1. Brooks R. EuroQol: the current state of play. Health Policy. 1996;37(1):53–72.
    1. Fransen M, Edmonds J. Reliability and validity of the EuroQol in patients with osteoarthiritis of the knee. Rheumatology. 1999;38:807–813.
    1. Dolan P. Modeling valuations for EuroQol health states. Med Care. 1997;35(11):1095–1108.
    1. Krol M, Brouwer W. How to estimate productivity costs in economic evaluations. Pharmacoeconomics. 2014;32(4):335–344.
    1. Pike J, Grosse SD. Friction cost estimates of productivity costs in cost-of-illness studies in comparison with human capital estimates: a review. Appl Health Econ Health Policy. 2018;16(6):765–778.
    1. Manca A, Hawkins N, Sculpher MJ. Estimating mean QALYs in trial-based cost-effectiveness analysis: the importance of controlling for baseline utility. Health Econ. 2005;14(5):487–496.
    1. Corp. I . IBM SPSS Statistics for Windows. 22.0 edn. Armonk: IBM Corp.; 2013.
    1. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care Programmes. Oxford: OUP; 2015.
    1. StataCorp . Stata Statistical Software. Release 17 edn. College Station: StataCorp LLC; 2021.
    1. Nationella riktlinjer för rörelseorganens sjukdomar. Metodbeskrivning. Bilaga. Nationella riktlinjer för rörelseorgnanens sjukdomar - Reumatoid artrit, axial spondylartrit, psoriasisartrit, artros och osteoporos - Stöd för styrning och ledning 2021. : National Board of Health and Welfare; 2021.
    1. Almén A, Jangland L. Swedish Radiation Safety Authority. 2020. Myndighetsrapport - Radiologiska undersökningar i Sverige under 2018.
    1. Limbäck Svensson G, Wetterling W. BOA - Bättre omhändertagande av patienter med artros. Årsrapport 2019. 2020.
    1. Kouropoulos G. A predictive model for the estimation of carbon dioxide emissions of magnetic resonance imaging units and computed tomography scanners. JUEE. 2018;12(2):172–187.
    1. Bornhoft L, Larsson ME, Thorn J. Physiotherapy in primary care triage - the effects on utilization of medical services at primary health care clinics by patients and sub-groups of patients with musculoskeletal disorders: a case-control study. Physiother Theory Pract. 2015;31(1):45–52.
    1. Bornhoft L, Larsson ME, Nordeman L, Eggertsen R, Thorn J. Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial. Ther Adv Musculoskelet Dis. 2019;11:1759720X19827504.
    1. Bornhöft L, Thorn J, Svensson M, Nordeman L, Eggertsen R, Larsson MEH. More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment. BMC Musculoskelet Disord. 2019;20(1):186.
    1. Zuidgeest MGP, Goetz I, Groenwold RHH, Irving E, van Thiel G, Grobbee DE. Series: pragmatic trials and real world evidence: paper 1. Introduction. J Clin Epidemiol. 2017;88:7–13.
    1. Lentz TA, Goode AP, Thigpen CA, George SZ. Value-based care for musculoskeletal pain: are physical therapists ready to deliver? Phys Ther. 2020;100(4):621–632.
    1. Hiligsmann M, Cooper C, Guillemin F, Hochberg MC, Tugwell P, Arden N, Berenbaum F, Boers M, Boonen A, Branco JC, et al. A reference case for economic evaluations in osteoarthritis: an expert consensus article from the European Society for Clinical and Economic Aspects of osteoporosis and osteoarthritis (ESCEO) Semin Arthritis Rheum. 2014;44(3):271–282.
    1. Davidsson L, Rödholm M: Projekt - Oberoende av inhyrd personal. Rapport från det nätverksgemensamma projektet 2016–2018. Sveriges kommuner och landsting; 2019.
    1. Kostnader för inhyrd personal i hälso- och sjukvården 2020. I jämförelser med helår/2019 samt halvår 2/2019. Sveriges Kommuner och Regioner; 2020.
    1. Christiansen ASJ, Møller MLS, Kronborg C, Haugan KJ, Køber L, Højberg S, et al. Comparison of the three-level and the five-level versions of the EQ-5D. Eur J Health Econ. 2021;22;621-8.
    1. Agborsangaya CB, Lahtinen M, Cooke T, Johnson JA. Comparing the EQ-5D 3L and 5L: measurement properties and association with chronic conditions and multimorbidity in the general population. Health Qual Life Outcomes. 2014;12:74.
    1. Wailoo A, Alava MH, Pudney S, Barton G, O'Dwyer J, Gomes M, Irvine L, Meads D, Sadique Z. An international comparison of EQ-5D-5L and EQ-5D-3L for use in cost-effectiveness analysis. Value Health. 2021;24(4):568–574.
    1. Hernandez Alava M, Wailoo A, Grimm S, Pudney S, Gomes M, Sadique Z, Meads D, O'Dwyer J, Barton G, Irvine L. EQ-5D-5L versus EQ-5D-3L: the impact on cost effectiveness in the United Kingdom. Value Health. 2018;21(1):49–56.
    1. Pennington B, Hernandez-Alava M, Pudney S, Wailoo A. The impact of moving from EQ-5D-3L to -5L in NICE technology appraisals. Pharmacoeconomics. 2019;37(1):75–84.
    1. Zhao T, Winzenberg T, de Graaff B, Aitken D, Ahmad H, Palmer AJ. A systematic review and meta-analysis of health state utility values for osteoarthritis-related conditions. Arthritis Care Res. 2020;74(2):291-300.
    1. Briani RV, Ferreira AS, Pazzinatto MF, Pappas E, De Oliveira SD, Azevedo FM. What interventions can improve quality of life or psychosocial factors of individuals with knee osteoarthritis? A systematic review with meta-analysis of primary outcomes from randomised controlled trials. Br J Sports Med. 2018;52(16):1031–1038.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する